The Cautionary Tale of CMS’s New Policies for Global Surgery Payment Accuracy

The Centers for Medicare & Medicaid Services (CMS) continues to refine policies to address the evolving needs of the healthcare system, with an eye on accuracy and fairness in payment models. For CY 2025, CMS is finalizing significant changes to global surgery payment rules that are poised to impact practitioners across various settings. While these changes aim to improve payment accuracy, they come with potential risks that providers should not overlook.

Overview of the Policy Changes

CMS has introduced two key updates:

1. Expanded Use of Modifier 54:
   Practitioners performing only the surgical procedure portion of a 90-day global surgical package can now use Modifier 54 more broadly. This includes cases of informal, non-documented transfers of care, in addition to the formally documented transfers permitted under previous rules.
2. New HCPCS Code G0559:
   This add-on code accounts for post-operative care services furnished by a practitioner other than the one who performed the surgery (or another practitioner in the same group practice). It reflects the time and resources involved in follow-up care and ensures that payment is more accurately aligned with the services provided.

The Risk of Misapplication: Medically Necessary or Policy-Driven?

On the surface, these updates appear to create more equitable reimbursement structures. However, a closer look reveals potential pitfalls:

• Hospital Policies vs. Medical Necessity:
  Many hospitals rely on hospitalists or other practitioners to see patients during a global period, even when such visits may not be clinically warranted. These visits, often driven by hospital policy rather than true medical necessity, could lead to improper use of the new add-on code or Modifier 54.
• Audit Vulnerabilities:
  While HCPCS code G0559 offers an avenue for fair reimbursement, its use opens the door to increased scrutiny. Misuse or overuse of this code could trigger large-scale audits, particularly if the visits it represents lack sufficient documentation or justification of medical necessity.

How to Protect Your Practice: Stay Vigilant

To avoid the compliance risks associated with these changes, healthcare providers must implement proactive strategies:

1. Ensure Medical Necessity:
   Before appending Modifier 54 or HCPCS code G0559, confirm that the visit or transfer of care is medically necessary and not merely a matter of hospital policy. Establish clear guidelines to distinguish necessary services from routine or policy-driven practices.
2. Strengthen Documentation Practices:
   Documentation is your first line of defense against audit risks. Ensure that all visits, whether during the global period or not, are thoroughly documented to support their medical necessity.
3. Educate Your Team:
   Provide training for billing and clinical staff to understand the appropriate use of Modifier 54 and HCPCS code G0559. Clear communication across departments can minimize the risk of errors and ensure compliance.
4. Audit Before the Auditors:
   Conduct regular internal audits of your billing practices to identify and correct errors early. This is especially critical for global surgery payments, where mistakes can lead to significant financial repercussions.

Conclusion

CMS’s updates for CY 2025 aim to create a more accurate payment system for global surgical packages, but they also carry inherent risks. Providers should tread carefully, ensuring that services billed under these new policies are grounded in medical necessity and backed by robust documentation. By staying vigilant and proactive, your practice can adapt to these changes while avoiding the compliance pitfalls that could lead to audits or denials.

The new policies may offer opportunities for fair reimbursement, but with these opportunities comes the responsibility to ensure compliance. Remember, the key to success lies in balancing the promise of payment accuracy with the caution required to navigate a more complex regulatory landscape.

 

About: Shannon O. DeConda, CPC, CPMC, CEMC, CEMA, CPA-EDU, CRTT, CPA-R

Ms. DeConda has devoted her entire career to healthcare, starting as a front-desk receptionist and progressing through roles in medical assisting, respiratory therapy, practice management, billing and denials support, and in-office coding, auditing, and education.

In 2007, she founded the National Alliance of Medical Auditing Specialists (NAMAS)—the first organization to formally educate medical auditors and the original creators of the CPMA credential. Today, as President of NAMAS and as the VP of Regulatory Compliance with the parent company, DoctorsManagement, Ms. DeConda continues to elevate industry standards, providing essential resources and training to healthcare professionals nationwide.